2013;100(3) – ABC CARDIOL

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Artigo Original

Role of BNP levels on the prognosis of decompensated advanced heart failure

Antônio Carlos Pereira-Barretto et al. Carlos Henrique Del Carlo Juliano Novaes Cardoso Marcelo Eid Ochiai … Marcelo Villaça Lima Milena Cardoso Curiati Airton Roberto Scipioni José Antônio Franchini Ramires

BACKGROUND: Heart failure (HF) is a condition with poor outcome, especially in advanced cases. Determination of B-type natriuretic peptide (BNP) levels is useful in the diagnosis of cardiac decompensation and has also been proving useful in the prognostic evaluation. OBJECTIVES: To verify whether BNP levels are able to identify patients with a poorer outcome and whether it is an independent prognostic factor considering age, gender, cardiac and renal functions, as well as the cause of heart disease. METHODS: 189 patients in functional class III/IV advanced HF were studied. All had systolic dysfunction and had their BNP levels determined during hospitalization. Variables related to mortality were studied using univariate and multivariate analyses. RESULTS: BNP levels were higher in patients who died in the first year of follow-up (1,861.9 versus 1,408.1 pg/dL; p = 0.044) and in chagasic patients (1,985 versus 1,452 pg/mL; p = 0.001); the latter had a higher mortality rate in the first year of follow-up (56% versus 35%; p = 0.010). The ROC curve analysis showed that the BNP level of 1,400 pg/mL was the best predictor of events; high levels were associated with lower LVEF (0.23 versus 0.28; p = 0.002) and more severe degree of renal dysfunction (mean urea 92 versus 74.5 mg/dL; p = 0.002). CONCLUSION: In advanced HF, high BNP levels identified patients at higher risk of a poorer outcome. Chagasic patients showed higher BNP levels than those with heart diseases of other causes, and have poorer prognosis.

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Erratum

Issue of July 2012, vol. 99 (1), pp. 576-585

ERRATA

Issue of July 2012, vol. 99 (1), pp. 576-585

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Letter to the Editor

Cardiology and Public health: 40 years

Maria Inês Reinert Azambuja

LETTER TO THE EDITOR

Cardiology and Public health: 40 years

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Review Article

CHADS2 score in predicting cerebrovascular events: a meta-analysis

Cristina Santos et al. Telmo Pereira Jorge Conde

REVIEW ARTICLE

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Letter to the Editor

Serum cystatin c levels should correlate with endothelial dysfunction and inflammation indirectly through renal function

Sait Demirkol et al. Mustafa Cakar Sevket Balta Murat Unlu … Omer Kurt Muharrem Akhan

LETTER TO THE EDITOR

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Artigo Original

Results of simplified single-patch repair for complete atrioventricular septal defect

Ana Paula Tagliari et al. Daniel Augusto Schröder Guaracy Teixeira Filho Paulo Roberto Prates … João Ricardo M. Sant'Anna Ivo A. Nesralla Renato A. K. Kalil

BACKGROUND: Since Wilcox’s description of the simplified single-patch technique for atrioventricular septal defect (AVSD) repair in 1997, several studies have compared that technique with the two-patch technique. OBJECTIVE: To report the mid- and long-term results of the simplified single-patch technique for complete AVSD repair. METHODS: Retrospective study of 16 consecutive cases between January 2001 and December 2011. The patients’ mean age was 18.31 ± 34.19 months (2 months – 11 years), and their mean weight, 7.80 ± 6.12 kg (3.77 – 25.0 kg). Six patients were males and 14 had Down syndrome. Mean follow-up duration was 54.97 ± 47.79 months. RESULTS: Mean cardiopulmonary bypass time was 74.63 ± 18.48 min (49 – 112 min), and mean aortic cross-clamp time, 46.44 ± 11.89 min (34 – 67 min). Two patients died during hospitalization (12.5%), both of cardiovascular causes. Three patients underwent reoperation due to left atrioventricular (AV) valve regurgitation, and two had third-degree VA block, requiring permanent pacemaker implantation. No patient had left ventricular outflow tract obstruction. The 14 surviving patients remain asymptomatic, ten of whom with mild left VA valve regurgitation (71.42%). CONCLUSION: The simplified single-patch technique for complete AVSD repair proved to be feasible, providing adequate correction of the defects and favorable clinical and echocardiographic outcome in the mean 57.97-month follow-up.

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Artigo Original

Pre-participation ECG screening in military recruits

Alon Grossman et al. Alex Prokupetz Igor Lipchenca

BACKGROUND:The findings and additional investigations required based on pre-participation electrocardiography (ECG) among military recruits are poorly defined in the literature. OBJECTIVES: This study was designed to evaluate the rate of abnormal findings on pre-participation ECG in young adults and the additional evaluations required based on these findings. METHODS: A retrospective cohort study was performed in the Israeli Air Force (IAF) aero medical screening center for flight academy and elite units’ candidates. Flight academy and elite units’ candidates undergo pre-participation ECG prior to enlistment to the Israeli Defense Forces (IDF). Since 2010, all ECGS have been performed at the IAF aero medical center. All ECGs performed since January 2010 were analyzed by one of three cardiologists and all those in which significant findings were identified were referred to further evaluation upon the cardiologist’s request. Causes of referral for further evaluation, the evaluations performed and the results of these evaluations are reported for the study population. RESULTS: 1455 ECGS were performed in the years 2010-2011. Of these, 1388 (95.39%) were interpreted as normal. 67 subjects were referred to further evaluation based on ECG findings. The most common findings leading to further evaluation were T wave changes (16 cases, 23.88%), pre-excitation pattern (14, 20.89%) and voltage criteria for left ventricular hypertrophy (11, 16.41%). Only 7 subjects (10.44%) had abnormal findings which were considered clinically significant at the end of the medical evaluation. CONCLUSIONS: The rate of significant findings leading to disqualification from military activity is extremely low and referral to continued investigations based on 12-lead ECG findings should be judicious.

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Viewpoint

Prudence in approaching valvular heart disease

VIEWPOINT

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Artigo Original

Lower than normal mean platelet volume is associated with reduced extent of coronary artery disease

Tolga Sinan Güvenç et al. Hakan Hasdemir Hatice Betül Erer Erkan İlhan … Kazım Serhan Özcan Ali Nazmi Çalık Rengin Çetin Mehmet Eren

BACKGROUND: Extent of atherosclerotic coronary artery disease in patients with stable angina has important prognostic and therapeutic implications. In current models of plaque evolution, thrombocytes play an important role in plaque growth. Mean platelet volume is a readily obtainable marker that was shown to correlate with platelet aggregability in vitro and increased values were demonstrated after acute vascular events. OBJECTIVE: In this study, we investigated the relationship of mean platelet volume and angiographic extent of coronary artery disease in patients with stable angina. METHODS: Past medical records, complete blood count and angiographic data of 267 eligible stable angina patients were reviewed. Angiographic extent of coronary artery disease was evaluated form angiographic data using Gensini score by an expert in invasive cardiology. Mean platelet volume values were obtained from complete blood counts that obtained one day before angiography. Patients were grouped as those within (n = 176) and lower than (n = 62) population-based range for mean platelet volume. Comparison between groups and correlation analysis was performed. RESULTS: There were no linear correlation between total Gensini score and mean platelet volume (p = 0.29), while total thrombocyte count was inversely correlated with mean platelet volume (p < 0.001; r = 0.41). Patients with lower than normal mean platelet volume had significantly lower Gensini score (36.73 ± 32.5 vs. 45.63 ± 32.63; p = 0.023) and three-vessel disease (18% vs. 36%; p = 0.007) compared with those mean platelet volume values within population-based ranges. CONCLUSION: Our findings show no linear relationship exists between mean platelet volume and extent of coronary artery disease, while patients with lower than normal mean platelet volume had reduced extent of coronary artery disease.

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Artigo Original

Smoking is associated with remodeling of gap junction in the rat heart: smoker's paradox explanation?

Rosangela Novo et al. Cristiana M. Freire Sergio Felisbino Marcos F. Minicucci … Paula S. Azevedo Leonardo A. M. Zornoff Sergio A. R. Paiva

BACKGROUND: In a previous study utilizing the rat model, exposure to tobacco smoke for 5 weeks increased survival after AMI, despite similar age and infarct size between the smokers and nonsmokers, and absence of reperfusion. OBJECTIVE: Thus, this study aimed to analyze the effects of exposure to tobacco smoke on intensity, distribution or phosphorylation of connexin 43 in the rat heart. METHODS: Wistar rats weighing 100 g were randomly allocated into 2 groups: 1) Control (n = 25); 2) Exposed to tobacco smoke (ETS), n = 23. After 5 weeks, left ventricular morphometric analysis, immunohisthochemistry and western blotting for connexin 43 (Cx43) were performed. RESULTS: Collagen volume fraction, cross-sectional areas, and ventricular weight were not statistically different between control and ETS. ETS showed lower stain intensity of Cx43 at intercalated disks (Control: 2.32 ± 0.19; ETS: 1.73 ± 0.18; p = 0.04). The distribution of CX43 at intercalated disks did not differ between the groups (Control: 3.73 ± 0.12; ETS: 3.20 ± 0.17; p = 0.18). ETS rats showed higher levels of dephosphorylated form of Cx43 (Control: 0.45 ± 0.11; ETS: 0.90 ± 0.11; p = 0.03). On the other hand, total Cx43 did not differ between control and ETS groups (Control: 0.75 ± 0.19; ETS: 0.93 ± 0.27; p = 0.58). CONCLUSION: Exposure to tobacco smoke resulted in cardiac gap junction remodeling, characterized by alterations in the quantity and phosphorylation of the Cx43, in rats hearts. This finding could explain the smoker’s paradox observed in some studies.

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Artigo Original

Study of ventricular electrical systole in patients with end-stage kidney disease on hemodialysis

Bruno Valentim et al. Alexandre Pereira Patrícia Coelho Telmo Pereira

BACKGROUND: Patients with end-stage kidney disease (ESKD) experience elevated cardiac stress because of the repetitive and intermittent character of dialysis. Changes in ventricular electrical systole induced by necessary dialysis significantly contribute to predict sudden death due to arrhythmia in ESKD. OBJECTIVE: The major objective of this study was to assess the behavior of ventricular repolarization in dialysis by analyzing QTc interval and QTc dispersion. METHODS: This study sample consisted of 47 patients undergoing hemodialysis (61.7% males and 38.3% females), whose mean age was 66.79±13.16 years. All of them underwent three electrocardiograms performed before, during and after one dialysis session. Ventricular electrical systole was analyzed later. RESULTS: An increase in maximum QTc interval and QTc dispersion associated with dialysis was observed. In addition, an increase in the number of individuals meeting the electrocardiographic criteria for left ventricular hypertrophy (LVH) was observed. After dialysis, higher means of the maximum QTc interval (473 ± 27.63 mseg) and of the QTc dispersion (58.95 ± 18.87 mseg) were observed in individuals with LVH as compared with those in individuals without LVH (455.21 ± 26.85 mseg and 44 ± 16.41 mseg, respectively). CONCLUSION: This study confirmed an increase in the QTc interval and QTc dispersion associated with dialysis. That emphasizes the dependence of ventricular repolarization on fluid and electrolyte balance, and suggests a profile of higher vulnerability to arrhythmia associated with dialysis .

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Case Report

Double valve replacement due to dysfunction secondary to carcinoid tumor

Paulo Manuel Pêgo-Fernandes et al. André Micheletto Laurino Danilo de Souza Ferronato Frederico Perego Costa … Ramez Anbar Fabio Biscegli Jatene

CASE REPORT

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Artigo Original

Correlation between myocardial scintigraphy and ct angiography in the evaluation of coronary disease

Jader Cunha de Azevedo et al. Diógenes de Souza Ferreira Junior Felipe Carvalhinho Vieira Laís Santos Prezotti … Luciana Silveira Simões Marcelo Souto Nacif Carlos Eduardo Rochitte Amarino de Carvalho Oliveira Junior Evandro Tinoco Mesquita Cláudio Tinoco Mesquita

BACKGROUND: Coronary multidetector CT angiography (CTA) has shown good accuracy for detection of coronary stenosis. Although this is a promising technique for the evaluation of CAD, its correlation with the functional expression of the disease is not yet well established. OBJECTIVE: To evaluate whether the presence of CAD and the degree of coronary stenosis assessed by CT angiography are associated with changes in the Myocardial Perfusion Scintigraphy (MPS). METHODS: This is a retrospective observational study, which included 99 consecutive patients with known or suspected CAD. MPS and CTA were conducted. We compared the presence of perfusion defects by MPS with the presence of CAD and the degree of luminal obstruction by CTA. For statistical analysis, Student’s t-test, ANOVA, and Chi-square (or Fisher’s exact test for n <5) tests were used. Multivariate analysis was performed using logistic regression: the level of significance was 5%. RESULTS: Mean age was 62 ± 11.4 years, with 46 (71.7%) men. The variable analysis was performed per patient (n = 99) and per coronary irrigation territory (n = 297). Of the 67 territories that had significant CAD by CTA, 44.8% had abnormal MPS. Considering the degree of stenosis, abnormal MPS was present in 18.7% of the territories with no significant stenosis, 45.28% of the territories with moderate stenosis, and 42.8% of the territories with severe injuries. CONCLUSIONS: CTA is a good method for exclusion of CAD. However, its use to evaluate the severity of stenosis and its functional impact has not shown good correlation.

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Artigo Original

InsCor: a simple and accurate method for risk assessment in heart surgery

Omar A. V. Mejía et al. Luiz A. F. Lisboa Luiz B. Puig Luiz Felipe P. Moreira … Luis A. O. Dallan Pablo M. A. Pomerantzeff Fabio B. Jatene Noedir A. G. Stolf

BACKGROUND: Risk scores show difficulties to attain the same performance in different populations. OBJECTIVE: To create a simple and accurate risk assessment model for patients submitted to surgery due to coronary and/or valvular disease at Instituto do Coração da Universidade de São Paulo (InCor-HCFMUSP). METHODS: Between 2007 and 2009, 3,000 patients were submitted to surgical procedure due to coronary artery and/or valvular disease at InCor-HCFMUSP. From this record, data of 2/3 of the patients were used for model development (bootstrap technique), and 1/3 for internal validation of the model. The performance of the model (InsCor) was compared to the 2000 Bernstein-Parsonnet (2000BP) and EuroSCORE (ES) complexes. RESULTS: Only 10 variables were selected: age > 70 years, female sex; coronary revascularization + valve, myocardial infarction < 90 days; reoperation; surgical treatment of aortic valve; surgical treatment of tricuspid valve; creatinine < 2mg/dL; ejection fraction < 30%, and events. The Hosmer Lemeshow test for the InsCor was 0.184, indicating excellent calibration. The area under the ROC curve was 0.79 for the InsCor, 0.81 for the ES and 0.82 for 2000BP, confirming that the models are good and have similar discrimination. CONCLUSIONS: The InsCor and ES performed better than 2000BP at all stages of validation, but the new model, in addition to showing identification with the local risk factors, is simpler and more objective for mortality prediction in patients undergoing surgery due to coronary and/or valvular disease at InCor-HCFMUSP.

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Artigo Original

High on-treatment platelet reactivity predicts cardiac events in patients with drug-eluting stents

Aline Sterque Villacorta et al. Humberto Villacorta Junior Marcos J. S. Batista Renato Villela Gomes … Luiz Augusto Macedo Bruno Helmuth Evandro Tinoco Mesquita

BACKGROUND: The role of platelet reactivity (PR) tests in the prediction of long-term events in Latin-American patients treated with drug-eluting stents (DES) has not been established. OBJECTIVES: To assess the role of PR tests in the prediction of events after DES implantation. METHODS: From May 2006 through January 2008, 209 Brazilian patients who underwent elective treatment with DES were included. PR was assessed 12 to 18h after the procedure by light transmittance aggregometry with 5µM of ADP. Patients were prospectively followed for up to 4.8 years. Seventeen (8%) individuals were lost to follow-up and the final cohort comprised 192 patients. Receiver operating curve (ROC) was used to determine the best 5µM of ADP cutoff to predict events. The primary endpoint was a combination of cardiovascular death, acute myocardial infarction, definite stent thrombosis, and target-artery revascularization. Cox proportional hazard models were used to determine the variables independently associated with the time to the first event. RESULTS: The best ADP 5µM cutoff was 33%. One hundred and seven (55.7%) patients had ADP 5µM >33%. Event-free survival rate at 1,800 days was 55% vs. 70% for individuals with ADP5 above and below such cutoff, respectively (p=0.001). Independent predictors of time to first event were current smoking (HR 3.49; 95% CI 1.76-6.9; p=0.0003), ADP 5µM >33% (HR 1.95; 95% CI 1.09-3.51; p=0.025) and age (HR 1.03; 95% CI 1.0-1.06; p=0.041). CONCLUSIONS: In this study, 55.7% of the patients had high on-treatment platelet reactivity. ADP 5µM >33% was an independent predictor of long-term events.

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Artigo Original

Influence of long-term obesity on myocardial gene expression

Ana Paula Lima-Leopoldo et al. André Soares Leopoldo Danielle Cristina Tomaz Silva André Ferreira do Nascimento … Dijon Henrique Salomé de Campos Renata de Azevedo Melo Luvizotto Silvio Assis de Oliveira Júnior Carlos Roberto Padovani Célia Regina Nogueira Antonio Carlos Cicogna

BACKGROUND: Several authors have shown that deterioration of cardiac function is associated with the degree and duration of obesity. It is necessary to establish the gene expression patterns after prolonged periods of obesity. OBJECTIVE: This study tested the hypothesis that increased duration of exposure to obesity leads to a reduction in the mRNA levels of proteins involved in regulation of myocardial Ca2+ homeostasis. In addition, this study verified whether the decrease in mRNA expression was caused by a reduction in thyroid hormone. METHODS: Thirty-day-old male Wistar rats were distributed in two groups: control (C) and obese (Ob). The C group was fed a standard diet and the Ob was fed with high-fat diets for 15, 30 and 45 weeks. Obesity was defined by adiposity index. The gene expression was assessed by quantitative real-time PCR. RESULTS: The adiposity index was higher in the Ob compared to the C after all periods. While obesity at 15 and 45 weeks resulted in a reduction in mRNA of sarcoplasmic reticulum Ca2+- ATPase (SERCA2a), Na+/Ca2+ exchanger (NCX), and calsequestrin (CSQ), L-type Ca2+ channels, ryanodine receptor, SERCA2a, phospholamban (PLB), NCX, and CSQ expression were increased compared to the C after 30 weeks. There was no significant association between T3 levels and mRNA expression. CONCLUSIONS: Our data indicate that obesity over the short and long periods of time may promote alteration in gene expression of Ca2+ homeostasis regulatory proteins without influence by thyroid hormone.

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Clinicoradiological Session

Case 2/2013: 23-year-old woman with dilated right ventricle, with no residual defects after repair of tetralogy of fallot

CLINICORADIOLOGICAL SESSION

Case 2/2013 – 23-year-old woman with dilated right ventricle, with no residual defects after repair of tetralogy of fallot

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Case Report

Brugada-like electrocardiographic changes induced by hypokalemia

Guilherme Ferreira Gazzoni et al. Anibal Pires Borges Luis Carlos Corsetti Bergoli José Luiz Flores Soares … Carlos Kalil Eduardo Bartholomay

CASE REPORT

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Editorial

National physician qualification program in cardiovascular disease prevention and integral care

Jadelson Pinheiro de Andrade et al. Luiz Alberto Piva e Mattos Antonio Carlos Carvalho Carlos Alberto Machado Glaucia Maria Moraes de Oliveira

EDITORIAL

National physician qualification program in cardiovascular disease prevention and integral care

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Special Article

Evidence-based therapy prescription in high-cardiovascular risk patients: the REACT study

Otávio Berwanger et al. Luiz Alberto Piva e Mattos José Fernando Vilela Martin Renato Delascio Lopes … Estevão Lanna Figueiredo Daniel Magnoni Dalton Bertolim Precoma Carlos Alberto Machado Jorge Ilha Guimarães Jadelson Pinheiro de Andrade

BACKGROUND: Data on outpatient care provided to patients at high cardiovascular risk in Brazil are insufficient. OBJECTIVE: To describe the profile and document the clinical practice of outpatient care in patients at high cardiovascular risk in Brazil, regarding the prescription of evidence-based therapies. METHODS: Prospective registry that documented the ambulatory clinical practice in individuals at high cardiovascular risk, which was defined as the presence of the following factors: coronary artery disease, cerebrovascular and peripheral vascular diseases, diabetes, or those with at least three of the following factors: hypertension, smoking, dyslipidemia, age > 70 years, family history of coronary artery disease, chronic kidney disease or asymptomatic carotid artery disease. Basal characteristics were assessed and the rate of prescription of pharmacological and non-pharmacological interventions was analyzed. RESULTS: A total of 2364 consecutive patients were included, of which 52.2% were males, with a mean age of 66.0 years (± 10.1). Of these, 78.3% used antiplatelet agents, 77.0% used statins and of patients with a history of myocardial infarction, 58.0% received beta-blockers. Concomitant use of these three classes of drugs was 34%; 50.9% of hypertensive, 67% of diabetic and 25.7% of dyslipidemic patients did not achieve the goals recommended by guidelines. The main predictors of prescription therapies with proven benefit were centers with a cardiologist and history of coronary artery disease. CONCLUSION: This national and representative registry identified important gaps in the incorporation of therapies with proven benefit, offering a realistic outlook of patients at high cardiovascular risk.

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